How to Treat Retrocalcaneal Bursitis

One of the most common causes of pain and swelling on the back of the heel is retrocalcaneal bursitis. It occurs when the bursa attached deep between the heel bone (calcaneus) and the Achilles tendon becomes inflamed. This small sac lined with a synovial membrane serves to fluidize movements to help protect the tissues from friction. Athletes who have to jump regularly or wear tight skates are often affected by this problem. Examples include figure skaters, field hockey players and basketball players. This type of bursitis normally occurs after a severe trauma, an injury to the tendon or repeated micro-injuries. It’s important to follow the progression of the inflammation and symptoms and if the pain persists or worsens, consult a podiatrist immediately.

How to Diagnose Bursitis Behind the Heel

The affected area may become warm, swollen and painful, especially with ankle movement. The diagnosis is made through a clinical examination where a podiatrist will palpate the back of the foot and ask questions about medical history and lifestyle habits related to the problem. 

If the condition is not visible or if there is any doubt, an ultrasound of the foot will show enlargement of the bursa and synovial membrane and may even reveal various factors contributing to the condition. Further investigation or puncture may be helpful to identify or rule out another condition. This may include the following:

• Bacterial infection or an inflammatory condition affecting soft tissue (psoriatic arthritis,   rheumatoid arthritis or gout).
• Achilles tendinopathy, where the irritation and risk of tearing is not in the bursa, but rather in the substance of the tendon or at the point of attachment of the calf behind the heel.
• Retroachilles bursitis, where the bursa involved is the one between the skin and the Achilles tendon on the surface, rather than the one between the bone and the tendon, which is deeper.
• Paratenonitis, which involves the protective covering of the Achilles tendon. 
• Haglund-type morphology, where the heel bone is particularly prominent and causes irritation of the Achilles tendon and the intervening bursa.

Knowing the exact cause(s) will make it easier to design the proper treatment plan and avoid complications.

Treatments for Retrocalcaneal Bursitis

The basic recommendations for relief include reducing movement and compressive forces. Rest and ice to reduce swelling are also part of the immediate solutions. These seemingly simple basic practices must be done properly to avoid further irritation and to strengthen/soften the structures in order to limit the recurrence of bursitis. If sufficient flexibility is not achieved due to calf hypertonicity, a serial therapeutic taping protocol, podiatric orthotics and elevated footwear should be considered.

If your case is considered acute and causes significant limitations, more aggressive medical treatment will be recommended. This could include cortisone injections or a prescription for non-steroidal anti-inflammatory drugs (NSAIDs), administered orally or by injection. If the treatment involving cortisone infiltrations is recommended, you’ll need to wear an off-loading boot or a rigid restrictive bandage to protect the Achilles tendon from rupture. If it’s a bacterial infection, you’ll be prescribed an antibiotic. Finally, if you have calcifications, radial shock wave therapy may be proposed.

Many high-level athletes must or wish to continue their activities at all costs. However, recovery necessarily requires a period of rest and controlled movements. Therefore, whether your bursitis is mechanical, traumatic or related to a pathology, not treating it properly and believing that the condition is benign could lead to a loss of mobility. Remember, in this case, having cash on hand is not in your best interest at all!